Their value as predictors of VF is questionable and no specific therapy is required. In some cases, opioids are responsible. If accompanied by severe hypotension, sinus bradycardia should be treated with i. If so, atropine should be used first; if it fails, pacing should be instituted. Agents that slow AV conduction such as beta-blockers, digitalis, verapamil, or amiodarone should be used with caution.
AV sequential pacing should be considered in patients with complete AV block, RV infarction, and haemodynamic compromise. Revascularization should be considered in patients with AV block who have not yet received reperfusion therapy e. AV block associated with inferior wall infarction is usually supra-Hisian and usually resolves spontaneously or after reperfusion.
AV block associated with anterior wall MI is usually infra-Hisian and has a high mortality rate due to the extensive myocardial necrosis. The development of a new bundle branch block or hemiblock usually indicates extensive anterior MI. A transvenous pacing electrode should be inserted in the presence of advanced AV block with a low escape rhythm, as described above, and considered if bifascicular or trifascicular block develops. Indications for pacing are outlined in detail in the ESC Guidelines for cardiac pacing and cardiac resynchronization therapy.
Mechanical complications are life-threatening and need prompt detection and management. Sudden hypotension, recurrence of chest pain, new cardiac murmurs suggestive of mitral regurgitation or ventricular septal defect, pulmonary congestion, or jugular vein distension should raise suspicion. Immediate echocardiographic assessment is needed when mechanical complications are suspected. A full section describing mechanical complications can be found in the Web Addenda. Three major pericardial complications may occur: early infarct-associated pericarditis, late pericarditis or post-cardiac injury Dressler syndrome , and pericardial effusion.
These are expanded upon in the Web Addenda. MINOCA is a working diagnosis and should lead the treating physician to investigate underlying causes. Failure to identify the underlying cause may result in inadequate and inappropriate therapy in these patients. Table 10 Diagnostic criteria for myocardial infarction with non-obstructive coronary arteries adapted from Agewall et al Diagnostic criteria for myocardial infarction with non-obstructive coronary arteries adapted from Agewall et al The description of the pathophysiology of the different aetiological entities leading to MINOCA is beyond the scope of the present document, and has been extensively described and defined in position papers from the ESC 12 and in dedicated review papers.
The last two entities may mimic MI but are better classified as myocardial injury conditions. In general, after ruling out obstructive CAD in a patient presenting with STEMI, an LV angiogram or echocardiography should be considered in the acute setting to assess wall motion or pericardial effusion. In addition, if any of the possible aetiologies described above is suspected, additional diagnostic tests may be considered.
There is a wide practice gap between optimal and actual care for patients with STEMI in hospitals around the world. Quality indicators are intended to measure and compare the quality of health service provision and serve as a foundation for quality improvement initiatives.
Table 11 Quality indicators. Expanded text about quality indicators can be found in the Web Addenda. Despite the great advances in STEMI management over recent decades, important areas of uncertainty persist that should be explored in the future. Here, we identify some, but not all, specific areas that should be addressed within the next few years. Public campaigns aiming to increase early alerting of patients with ischaemic symptoms should clearly state that the safest way to alert is to call the EMS.
While selected centres and geographic areas have made great progress in ensuring high-quality rapid care for STEMI patients with routine pre-alert of the interventional team, there remains a need for streamlining of pre- hospital management in a homogeneous fashion worldwide, including rural areas. Educational programmes and cross-country exchange of experiences should help in this matter. The identification of the best cut-off timing to choose a strategy is of extreme importance. The introduction of a specific infarct-limiting therapy in clinical practice might have a massive clinical and socioeconomic impact.
One potential reason for this poor translation is the difficulty of securing funds to conduct proper large-scale clinical trials in this context. Despite major recent advances, important questions remain unaddressed. What is the best acute and maintenance antithrombotic regimen in patients who have an indication for oral anticoagulants? What is the best timing for the loading dose of oral P2Y 12 inhibitors and what are the best strategies for i.
What is the role of potent P2Y 12 inhibitors in patients undergoing fibrinolysis? What is the real role of aspirin in this new era of potent antiplatelet agents and low dose anticoagulation? What is the best duration of maintenance therapy with P2Y 12 inhibitors as single or multiple antithrombotic regimens? Although research regarding these classes of drugs was intense several decades ago, more recently, there has been a lack of properly powered clinical trials.
The best timing for initiation and route of administration of beta-blockers is still not well established.
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Similar limitations apply to the use of maintenance ACE inhibitors. The best management of non-IRA lesions should be addressed. Unresolved issues are the best criteria to guide PCI angiography, FFR, or assessment of plaque vulnerability and the best timing for complete revascularization if indicated during index PCI or staged, including staged during hospitalization vs. Severe heart failure and shock are among the most important negative prognostic predictors in patients with STEMI. In addition to urgent revascularization of IRA and standard medical therapies for pre- and afterload reduction, there is limited evidence for the systematic use of inotropic and vasopressor agents as well as mechanical support.
Similarly, the benefit of routine complete revascularization during the index PCI procedure has not been formally demonstrated. Systematic evaluation of pharmacological and interventional strategies and LV assist devices for patients with shock are urgently needed. The effectiveness and safety of novel therapies able to replace dead myocardium or prevent poor remodelling e.
There is a strong need for basic research studies to better understand the biological processes involved in cardiac development and repair, in order for there to be strong grounds to translate studies into clinically relevant animal models and finally into humans. In order to understand shortcomings and challenges in clinical practice, for quality assessment and for benchmarking, unselected and validated registries and clinical databases are needed. In this document, we have specified quality indicators intended to measure and compare the quality of health service provision and serve as a foundation for quality improvement initiatives.
Their effects on procedural and clinical outcomes need to be evaluated. One major limitation of highly selective controlled clinical trials is their applicability in the real world. Strict inclusion criteria, tailored management, and very close follow-up results in a bias that precludes universal implementation. An opportunity is the implementation of pragmatic clinical trials including registry-based randomized clinical trials. Epidemiology of STEMI : Although the rate of mortality associated with ischaemic heart disease have reduced in Europe over the last few decades, this is still the single most common cause of death worldwide.
Despite the decline in acute and long-term death associated with STEMI, in parallel with the widespread use of reperfusion, mortality remains substantial. It is important to highlight that women and men receive equal benefit from a reperfusion and other STEMI-related therapies, and so both genders must be managed equally.
In patients with the mentioned ECG changes and clinical presentation compatible with ongoing myocardial ischaemia, a primary PCI strategy i. Reperfusion strategy selection : STEMI diagnosis defined as the time at which the ECG of a patient with ischaemic symptoms is interpreted as presenting ST-segment elevation or equivalent is the time zero in the reperfusion strategy clock.
Patient transfer to the PCI centre should bypass the emergency department. In all cases, the decision to perform urgent coronary angiography should take into account factors associated with poor neurological outcome. Routine thrombus aspiration or deferred stenting are contraindicated. Management of non-IRA lesions : Treatment of severe stenosis evaluated either by angiography or FFR should be considered before hospital discharge either immediately during the index PCI or staged at a later time.
Fibrinolysis: enoxaparin unfractionated heparin may be alternative , and loading dose of aspirin and clopidogrel. Early ambulation and early discharge are the best option in uncomplicated patients. Consequently, time for implementing secondary prevention is limited highlighting the importance of close collaboration between all stakeholders. Special attention should be paid to dose adjustment of some pharmacological strategies in these subsets.
Patients with diabetes and those not undergoing reperfusion represent another subset of patients that require additional attention. It is important to perform additional diagnostic tests in these patients to identify the aetiology and tailor appropriate therapy, which may be different from typical STEMI. Quality indicators : In some cases, there is a gap between optimal guideline-based treatment and actual care of STEMI patients. In order to reduce this gap, it is important to measure established quality indicators to audit practice and improve outcomes in real-life.
The use of well-defined and validated quality indicators to measure and improve STEMI care is recommended. Sign In. Advanced Search. Article Navigation. Close mobile search navigation Article Navigation. Volume Article Contents. Table of Contents. Abbreviations and acronyms. What is new in the version? Emergency care. Reperfusion therapy. Management during hospitalization and at discharge. Long-term therapies for ST-segment elevation myocardial infarction.
Complications following ST-segment elevation myocardial infarction. Myocardial infarction with non-obstructive coronary arteries. Assessment of quality of care. Gaps in the evidence and areas for future research. Key messages. Web addenda. Oxford Academic. Google Scholar. Stefan James. Stefan Agewall. Manuel J Antunes. Chiara Bucciarelli-Ducci. Alida L P Caforio. Filippo Crea. John A Goudevenos. Sigrun Halvorsen. Gerhard Hindricks. Adnan Kastrati. Mattie J Lenzen. Eva Prescott. Marco Roffi. Marco Valgimigli.
Christoph Varenhorst. Pascal Vranckx. Cite Citation. Permissions Icon Permissions. Table 1. Table 2. Figure 1. View large Download slide. Table 3. Table 4. Relief of hypoxaemia and symptoms. Cardiac arrest. Figure 2. Figure 3. Recommendations for reperfusion therapy. View Large. Table 5. Table 6. Table 7. Table 8. Logistical issues for hospital stay.
Table 9. Figure 4. Figure 5. Figure 6. Figure 7. Recommendations for the management of cardiogenic shock in ST-elevation myocardial infarction. Management of atrial fibrillation. Management of ventricular arrhythmias and conduction disturbances in the acute phase. Long-term management of ventricular arrhythmias and risk evaluation for sudden death. Table Search ADS.
Systematic review of patients presenting with suspected myocardial infarction and nonobstructive coronary arteries. Acute myocardial infarction with no obstructive coronary atherosclerosis: mechanisms and management. ESC working group position paper on myocardial infarction with non-obstructive coronary arteries. Trends in mortality from ischemic heart disease and cerebrovascular disease in Europe: to Differential time trends of outcomes and costs of care for acute myocardial infarction hospitalizations by ST elevation and type of intervention in the United States, Reperfusion therapy for ST elevation acute myocardial infarction in Europe: description of the current situation in 30 countries.
Heart disease and stroke statistics— update: a report from the American Heart Association. Temporal trends and sex differences in revascularization and outcomes of st-segment elevation myocardial infarction in younger adults in the United States. Association of changes in clinical characteristics and management with improvement in survival among patients with ST-elevation myocardial infarction. Trends in hospital treatments, including revascularisation, following acute myocardial infarction, a multilevel and relative survival analysis for the National Institute for Cardiovascular Outcomes Research NICOR.
Gender in cardiovascular diseases: impact on clinical manifestations, management, and outcomes. Acute coronary syndromes without chest pain, an underdiagnosed and undertreated high-risk group: insights from the Global Registry of Acute Coronary Events. Temporal trends in patient and treatment delay among men and women presenting with ST-elevation myocardial infarction. Sex differences in management and mortality of patients with ST-elevation myocardial infarction from the Korean Acute Myocardial Infarction National Registry. Gender and in-hospital mortality of ST-segment elevation myocardial infarction from a multihospital nationwide registry study of 31, patients.
Women with acute coronary syndrome are less invasively examined and subsequently less treated than men. Gender disparity in cardiac procedures and medication use for acute myocardial infarction. Incidence of recognized and unrecognized myocardial infarction in men and women aged 55 and older: the Rotterdam Study. Chest pain relief by nitroglycerin does not predict active coronary artery disease. Integration of pre-hospital electrocardiograms and ST-elevation myocardial infarction receiving center SRC networks: impact on door-to-balloon times across 10 independent regions.
Effects of prehospital lead ECG on processes of care and mortality in acute coronary syndrome: a linked cohort study from the Myocardial Ischaemia National Audit Project. Urban and rural implementation of pre-hospital diagnosis and direct referral for primary percutaneous coronary intervention in patients with acute ST-elevation myocardial infarction. Improved survival associated with pre-hospital triage strategy in a large regional ST-segment elevation myocardial infarction program.
Electrocardiographic findings in acute right ventricular infarction: sensitivity and specificity of electrocardiographic alterations in right precordial leads V4R, V3R, V1, V2, and V3. Five hundred patients with myocardial infarction monitored within one hour of symptoms. Incidence of and outcomes associated with ventricular tachycardia or fibrillation in patients undergoing primary percutaneous coronary intervention.
Left circumflex occlusion in acute myocardial infarction from the National Cardiovascular Data Registry. Anatomic distribution of the culprit lesion in patients with non-ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention: findings from the National Cardiovascular Data Registry. Incidence, distribution, and prognostic impact of occluded culprit arteries among patients with non-ST-elevation acute coronary syndromes undergoing diagnostic angiography.
Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block. Patients with prolonged ischemic chest pain and presumed-new left bundle branch block have heterogeneous outcomes depending on the presence of ST-segment changes. Should the electrocardiogram be used to guide therapy for patients with left bundle-branch block and suspected myocardial infarction? Diagnosing acute myocardial infarction in patients with left bundle branch block. Lack of association between left bundle-branch block and acute myocardial infarction in symptomatic ED patients.
Primary angioplasty in acute myocardial infarction with right bundle branch block: should new onset right bundle branch block be added to future guidelines as an indication for reperfusion therapy? Early electrocardiographic diagnosis of acute myocardial infarction in the presence of ventricular paced rhythm. Magnitude and consequences of missing the acute infarct-related circumflex artery. Acute myocardial infarction due to left circumflex artery occlusion and significance of ST-segment elevation. Relationship of ST elevation in lead aVR with angiographic findings and outcome in non-ST elevation acute coronary syndromes.
Morphine decreases clopidogrel concentrations and effects: a randomized, double-blind, placebo-controlled trial. Morphine is associated with a delayed activity of oral antiplatelet agents in patients with ST-elevation acute myocardial infarction undergoing primary percutaneous coronary intervention. Determination of the role of oxygen in suspected acute myocardial infarction trial. Acute coronary angiography in patients resuscitated from out-of-hospital cardiac arrest: a systematic review and meta-analysis. Six-month outcome of emergency percutaneous coronary intervention in resuscitated patients after cardiac arrest complicating ST-elevation myocardial infarction.
Emergent percutaneous coronary intervention for resuscitated victims of out-of-hospital cardiac arrest. Immediate coronary angiography in survivors of out-of-hospital cardiac arrest. Executive summary. Duration of resuscitation efforts and functional outcome after out-of-hospital cardiac arrest: when should we change to novel therapies? Cognitive impairments in survivors of out-of-hospital cardiac arrest: a systematic review.
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Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. Efficacy of therapeutic hypothermia after out-of-hospital cardiac arrest due to ventricular fibrillation. Targeted temperature management at 33 degrees C versus 36 degrees C after cardiac arrest.
Hypothermia in acute coronary syndrome: brain salvage versus stent thrombosis? Post-resuscitation electrocardiograms, acute coronary findings and in-hospital prognosis of survivors of out-of-hospital cardiac arrest. Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest: a randomized clinical trial.
System delay and mortality among patients with STEMI treated with primary percutaneous coronary intervention. Association of rapid care process implementation on reperfusion times across multiple ST-segment-elevation myocardial infarction networks. Effect of prehospital cardiac catheterization lab activation on door-to-balloon time, mortality, and false-positive activation. Relation between door-to-balloon times and mortality after primary percutaneous coronary intervention over time: a retrospective study.
Percutaneous coronary intervention
Emergency department bypass for ST-segment-elevation myocardial infarction patients identified with a prehospital electrocardiogram: a report from the American Heart Association Mission: Lifeline program. Clinical Guide to Primary Angioplasty. Stephen Brecker , Martin Rothman. Primary angioplasty is a life-saving, minimally invasive emergency procedure increasingly used in the treatment of acute myocardial infarction. As the procedure further proves its effectiveness, it is imperative that all cardiologists have a comprehensive understanding of the major issues surrounding primary angioplasty.
This easy-to-use, clinicall. Inhalt Chapter 1 Epidemiology and Historical Perspectives. Chapter 2 Prehospital Diagnosis and Management. Chapter 4 The Definition of Myocardial Infarction. Chapter 5 Optimal Reperfusion Therapy. We enrolled the patients in a consecutive manner, and the decision to use primary angioplasty as therapeutics of revascularization was the responsibility of the assisting team.
The patients presenting for the procedure with a duration of myocardial infarction shorter than 12 hours were included in the study, even patients in cardiogenic shock, previous infarction, and with a previous revascularization procedure were included. The material used was that available at the laboratory, which may have varied according to the supplier and market prices.
The diameter of the balloon varied according to the diameter of the culprit artery, always aiming at the proportion of The thickness of the guide wire was 0. All patients received aspirin at the dosage of to mg, and 10, to 15, units of heparin prior to the procedure. The team in charge decided the use of other medications, such as ticlopidine and glycoprotein inhibitors, and stent implantation.
The procedure was performed with no control of the coagulation tests, and the technique, time of inflation, and pressure of the balloon were decided by the physician in charge of the procedure. Except when contraindications existed, all patients were maintained for at least 24 hours with heparin at the dosage of 20, to 25, units per day. After the procedure, the patients were referred to the coronary unit or returned to the emergency department.
All complications were registered for further analysis. Doppler echocardiography was always performed before hospital discharge to assess the ventricular function and the regional motility of the heart. The analysis of ventricular function was performed through the conventional manner and the method of acoustic quantification, which, according to Castro's report 33 , has a high correlation and concordance with the information obtained on cineangioventriculography.
After hospital discharge, the patients were scheduled to return for an ambulatory clinical visit and a new echocardiography in 6 to 12 months. In all patients who had completed the follow-up, echocardiography was repeated with acoustic quantification, preferably performed by the same examining physician. New coronary and noncoronary events, the patient's clinical condition, and the need for a new revascularization procedure or hospitalization were also recorded.
Those patients who missed the follow-up visits were contacted by telephone, telegram, or letter, and advised to seek the hospital for assessment. The angiographic analysis, due to its subjectiveness, was carried out by 2 interventional cardiologists, and, in case of disagreement, it was referred for a third opinion. Bivariate analysis was performed for the variables considered possible risk factors for mortality or for those considered potential confounders. The t test was used for continuous variables, and the chi-square test or Fisher exact test was used for categorical variables.
To assess the factors determining major and minor outcomes, models of logistic regression were used in which clinically significant variables were included according to theoretical assumptions. Assessment of survival was performed with the aid of the Kaplan-Meier method using life tables and graphs, which described the combined events during the total follow-up of the patients. The values for ventricular function obtained through echocardiography performed before and after the procedure were compared using the t test for paired samples.
The study's sample comprised consecutive patients. The general characteristics are shown in table I.
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The time estimated between pain onset and the beginning of the procedure was 3. In-hospital mortality was Table II shows the bivariate associations of the different factors with this worse in-hospital evolution. The variables independently associated with in-hospital mortality were analyzed with a model of multiple logistic regression tab. The mean duration of hospitalization was 8. Cardiac complications occurred in 21 In regard to the need for new revascularization procedures, new myocardial revascularization was required in 7 6.
Of the patients who survived, In 98 patients, echocardiography with acoustic quantification was performed to assess the ventricular function on the day of hospital discharge, and the mean ejection fraction of the patients was Ten Progression of the disease in a site other than that dilated was observed in 3 Before the date scheduled for reassessment, major clinical events occurred, and they are listed in table IV.
Of the patients who were discharged asymptomatic, 26 had 1 event, and 4 were lost or were withdrawn from the study; therefore, the clinical reassessment proposed was carried out in 70 patients, who represented Figure 1 shows the Kaplan-Meier curve depicting total survival until the date of the new medical visit, and survival free from an event until the end of the study. The mean follow-up was At the time of clinical follow-up, 57 Echocardiography with acoustic quantification was performed in all 70 patients who returned for follow-up with no clinical events.
The mean ejection fraction was It is noteworthy that, in these cases, no statistically significant difference was observed between the echocardiographic measurement at the time of hospital discharge The factors associated with worse clinical evolution major events through the bivariate analysis are shown in table V. A reduction in the rate of events was only observed in the patients with stent implantation and coronary disease restricted to 1 vessel. These variables, which associated with a higher incidence of events in an independent manner, were analyzed with a multiple logistic regression model tab.
Figure 2 shows, with the aid of a Kaplan-Meier curve, the best evolution during the period of observation of those patients who had received stents during primary angioplasty in regard to major events. Discussion Primary angioplasty is not the most common treatment for myocardial reperfusion at our institution. Primary angioplasty was the choice in the most severely ill patients, in those at higher risk, in those with contraindications to other procedures, and in those cases in which the soliciting physician was certain about that being the best method.
In regard to the predominance of the male sex, mean age, time delay for initiation of treatment, vessel treated, location of the infarct, and initial flow assessed according to the TIMI classification 34 , data are similar to those found in other series reported in the literature On the other hand, in regard to the previous pathological history, hypertension, tobacco use, diabetes mellitus, dyslipidemia, previous infarction, and obesity, these data are largely variable when compared with those of other series 28,35, This may be due to the fact that this was a heterogeneous nonrandomized population, and, therefore, not reliably representing all those patients with acute myocardial infarction.
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The high number of patients with Killip III and IV functional classes and with mean blood pressure below 60mmHg in our study is noteworthy. The reason for performing primary angioplasty for the treatment of acute myocardial infarction is difficult to compare, because most studies are randomized, and, consequently, only those 2 alternatives exist. Smyth et al 38 , in their cohort study in New Zealand, report data very similar to that here presented. Therefore, it seems that, in nonrandomized studies, the reasons are similarly distributed, considering local rules and routines.
The in-hospital mortality of The clinical trials are far less strict in defining success, considering only the patients undergoing the procedure and not the total sum of the randomized patients. In addition, in these clinical trials, the patients, in whom TIMI 2 flow is obtained, are included in the success group, and, frequently, those patients in poorer clinical condition are not considered.
To avoid the effect of colinearity, blood pressure was excluded from the model of multiple logistic regression, and, due to conceptual reasons, because survival was a criterion of success of the procedure, angiographic success was also excluded to avoid a confounding bias.
These findings are supported by those of the PAMI study 23 , MITI study 29 , and the studies by Garcia et al 39 and Azmus 41 , which proved that advanced age was a variable independently associated with higher mortality. Functional class, as defined by the criteria of Killip-Kimbal at hospital admission, was the major determinant of worse in-hospital evolution. Mortality in this subgroup was The occurrence of Better results are known to be directly related to the duration and quality of the procedure.